There is substantial evidence that blood cholesterol levels are causally related to the development and progression of coronary heart disease (CHD), and that alteration of cholesterol and lipoprotein levels can alter the clinical course of CHD. In 1984 the National Institutes of Health Consensus Development Conference reviewed the accumulated literature, and concluded that both population-based and patient-based approaches to lowering blood cholesterol levels were appropriate. Following the Consensus Conference report the National Cholesterol Education Program was developed, and an expert panel developed guidelines for screening and treatment. Dietary therapy is recommended for all adults with a blood cholesterol level >200 mg/dl; further classification and treatment is based on total cholesterol level; lipoprotein analysis; and risk factors. A series of algorithms guide the clinician to further dietary intervention, retesting, and pharmacologic therapy if needed. The physician has a large potential role in the screening and management of patients with elevated cholesterol levels. However, physicians are often uncomfortable with therapy to modify behavior, as they have little training in this area and have little experience in working with such ancillary personnel as registered dieticians (RDs). We are proposing a study to implement and evaluate the effects of a nutrition intervention training program for primary care internists and a structured office practice environment for nutrition management on eating patterns (i.e., reduction in the percent of calories from saturated fat) and serum LDL-C levels of patients at the Fallon Clinic, a large general medical clinic/Health Maintenance Organization (HMO); as well as on the nutrition intervention practices of these physicians. The target populations will consist of 36 general internists and their patients with blood LDL-C levels in the upper 25th percentile of the LDL-C distribution. The effectiveness of the interventions will be evaluated by a randomized controlled study design, in which 1500 eligible patients will be allocated by site to one of three conditions: control (1); physician nutrition counseling training (2); or physician nutrition counseling training + a structured office practice environment for nutrition management (3). A patient-centered physician nutrition counseling training package will be developed, as will a group- oriented RD intervention program. Study end-points will include a 7% drop in serum LDL-C, a decrease in saturated fat intake from 15% to 10% of total calories, and a stepwise increase in the number of intervention steps taken by the physicians in conditions 2 & 3. Evaluation will assess changes in individual patient blood LDL-C levels and saturated fat intake and physician attitudes and practices; measure achievement of the defined process objectives; and assess the cost-effectiveness of the delivered intervention. Patient knowledge, attitudes and behaviors related to cholesterol lowering, and other psychosocial and demographic variables of targeted patients will be assessed, as will physician knowledge, attitudes and practices related to cholesterol lowering. Changes in pre- and post- intervention measures will provide data for outcome evaluations.